HESI Case Study: Postpartum revision
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Meet the Client: Marie Wilson - Correct Answers-Marie Wilson is a 28-year-old client who is
gravida 2, para 2, and is transferred to the postpartum unit 1 hour after delivery of a 8 lb, 1 oz
female. She was in labor for 16 hours and forceps were used to assist with the delivery. Marie
was given an epidural for anesthesia that was effective. The labor and delivery nurse reported
that Marie had a 4th degree laceration and her pain was currently at a 3 out of 10 scale. Her
vital signs were stable and she was catheterized for 500 mL of light yellow urine just prior to
delivery. Mr. Wilson was at the bedside for delivery and appeared supportive.
Assessment - Correct Answers-A 1, 000 mL bag of Lactated Ringer's solution containing 10 units
of oxytocin (Pitocin) is infusing via an 18 gauge peripheral IV in the LFA at 125 mL/hr, with 300
mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinues
when the bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? - Correct Answers-uterine firmness
Early detection of, and intervention for, postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess Marie's vital signs, fundus,
perineum, vaginal bleeding, pain, leg movement, and IV every 15 mins. for the first hour and
then every hour for the next 3 hours. - Correct Answers-
Marie has minimal sensation in her lower extremities, due to the effects of the epidural
anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects
of epidural anesthesia? - Correct Answers-Risk for injury
The nurse performs the first assessment upon arrival to the postpartum unit. Where would the
nurse expect to palpate the fundus? - Correct Answers-1 cm above the umbilicus
What is the priority nursing action to address Marie's needs r/t the repair of her 4th degree
perineal laceration? - Correct Answers-Apply perineal ice packs consistently for the first 24 to
48 hours.
Postpartum Crisis - Correct Answers-Fifteen minutes after the initial assessment, the nurse finds
, Marie disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her
saturated with blood.
Which action is most important for the nurse to implement immediately? - Correct Answers-
Massage the fundus
What is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-Activate the priority call light from the bedside.
The nurse has requested assistance and personnel are on their way. While waiting for help to
arrive, what is the next priority action? - Correct Answers-Assess for bladder distention
The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist
the nurse with Marie. Which task is best delegated to the UAP during this crisis? - Correct
Answers-Obtain VS and SpO2
The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 mL
since delivery. Her blood pressure is 70/40 mm Hg, Pulse 120, RR 28, SpO2 73%. The HCP's
prescriptions include stat oxytocin (Pitocin) 10 units in each liter of normal saline to infuse at 40
milliunits/minute. The HCP also prescribes 0.2 mg methylergonovine maleate (Methergine) IM
to be given immediately. The vial of oxytocin (Pitocin) is labeled 20 units/mL. The vial of
methylergonovine (Methergine) is labeled 0.8 mg/mL. How many mL of oxytocin (Pitocin)
should the nurse draw up in the syringe to inject into the 1000 mL bag of NS? - Correct
Answers-0.5
How many mL of methylergonovine should the nurse draw up in the syringe to administer to
Marie? - Correct Answers-0.25
Initial Stabilization - Correct Answers-The oxytocin (Pitocin) has been infusing at the prescribed
rate for 20 minutes. The nurse reassesses the client.
Which finding is most indicative that the medication is reaching a therapeutic level? - Correct
Answers-Firm fundus
Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24
hours of delivery. Considering the client's history, what etiology is most likely? - Correct
Answers-Uterine atony
Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm
above the umbilicus. She is receiving O2 per nasal cannula at 4 L/min and has a SpO2 of 88%.
questions with certified answers . you got this
champ!
Meet the Client: Marie Wilson - Correct Answers-Marie Wilson is a 28-year-old client who is
gravida 2, para 2, and is transferred to the postpartum unit 1 hour after delivery of a 8 lb, 1 oz
female. She was in labor for 16 hours and forceps were used to assist with the delivery. Marie
was given an epidural for anesthesia that was effective. The labor and delivery nurse reported
that Marie had a 4th degree laceration and her pain was currently at a 3 out of 10 scale. Her
vital signs were stable and she was catheterized for 500 mL of light yellow urine just prior to
delivery. Mr. Wilson was at the bedside for delivery and appeared supportive.
Assessment - Correct Answers-A 1, 000 mL bag of Lactated Ringer's solution containing 10 units
of oxytocin (Pitocin) is infusing via an 18 gauge peripheral IV in the LFA at 125 mL/hr, with 300
mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinues
when the bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? - Correct Answers-uterine firmness
Early detection of, and intervention for, postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess Marie's vital signs, fundus,
perineum, vaginal bleeding, pain, leg movement, and IV every 15 mins. for the first hour and
then every hour for the next 3 hours. - Correct Answers-
Marie has minimal sensation in her lower extremities, due to the effects of the epidural
anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects
of epidural anesthesia? - Correct Answers-Risk for injury
The nurse performs the first assessment upon arrival to the postpartum unit. Where would the
nurse expect to palpate the fundus? - Correct Answers-1 cm above the umbilicus
What is the priority nursing action to address Marie's needs r/t the repair of her 4th degree
perineal laceration? - Correct Answers-Apply perineal ice packs consistently for the first 24 to
48 hours.
Postpartum Crisis - Correct Answers-Fifteen minutes after the initial assessment, the nurse finds
, Marie disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her
saturated with blood.
Which action is most important for the nurse to implement immediately? - Correct Answers-
Massage the fundus
What is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-Activate the priority call light from the bedside.
The nurse has requested assistance and personnel are on their way. While waiting for help to
arrive, what is the next priority action? - Correct Answers-Assess for bladder distention
The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist
the nurse with Marie. Which task is best delegated to the UAP during this crisis? - Correct
Answers-Obtain VS and SpO2
The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 mL
since delivery. Her blood pressure is 70/40 mm Hg, Pulse 120, RR 28, SpO2 73%. The HCP's
prescriptions include stat oxytocin (Pitocin) 10 units in each liter of normal saline to infuse at 40
milliunits/minute. The HCP also prescribes 0.2 mg methylergonovine maleate (Methergine) IM
to be given immediately. The vial of oxytocin (Pitocin) is labeled 20 units/mL. The vial of
methylergonovine (Methergine) is labeled 0.8 mg/mL. How many mL of oxytocin (Pitocin)
should the nurse draw up in the syringe to inject into the 1000 mL bag of NS? - Correct
Answers-0.5
How many mL of methylergonovine should the nurse draw up in the syringe to administer to
Marie? - Correct Answers-0.25
Initial Stabilization - Correct Answers-The oxytocin (Pitocin) has been infusing at the prescribed
rate for 20 minutes. The nurse reassesses the client.
Which finding is most indicative that the medication is reaching a therapeutic level? - Correct
Answers-Firm fundus
Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24
hours of delivery. Considering the client's history, what etiology is most likely? - Correct
Answers-Uterine atony
Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm
above the umbilicus. She is receiving O2 per nasal cannula at 4 L/min and has a SpO2 of 88%.
